The patient
Patient right profile
Bilateral Keratoconus induced by eye rubbing, stable since the first visit
Identity : Mr B.C
First visit : 10/25/2016
Last Visit : 01/23/2018
Mr. B.C is a 29-year-old man with no previous ophthalmic history, no known allergies or any history of keratoconus in the family. He complained of a progressive decrease in visual acuity, greater in the right than in the left eye, which was not correctable with a change of glasses. He has never worn contact lenses.
His Refraction at the first visit (on 10/25th/2016) was : RE 20/20 +0,75 (-3 x 45 °) and LE 20/20 -0,5 (-1,25 x 150 °).
Clinical examination with the slit lamp revealed a discrete irregular inferior corneal bulge in both eyes. The eyes were dry as well, with break up time < 8 seconds.
When asked about his working habits, the patient declared that he worked for long hours in front of the computer screen, and had been doing overnight shifts for the last 4 years. He admitted that he rubbed his eyes a lot to relieve visual fatigue. His right eye was generally more uncomfortable and irritable as it was prone to recurrent chalazia (a chalazion is a swelling in the eyelid due to a blocked meibomian (oil) gland). He rubbed with both fists using grinding and rotatory movements, with the knuckles in direct contact with the eyelids.
He is right-handed and sleeps preferentially on the right side.
We urged him to stop rubbing his eyes definitely and treated his dry eye problem with lubricants.
At his subsequent review a month from the first visit, he verbalized that he was rubbing his eyes more often and more vigorously than he had realized at the first visit.
PATIENT RUBBING HIS EYES
HIS SLEEPING POSITIONHere are the Orbscan and ORA (Ocular Response Analyzer) maps of the first visit .
ORBSCAN, RIGHT EYE: Note the marked vertical asymmetry in the curvature map (bottom left). The apex of the corneal protrusion is better appreciated on the anterior elevation map (top left).
ORBSCAN LEFT EYE. As for the right eye, the early keratoconus pattern is obvious, but less pronounced.
ORA RIGHT EYE. Note the reduced height of the applanation peaks.
ORA LEFT EYE. The signals are altered, but the peaks are sligthly higher than in the right eye, suggesting lesser biomechanical compromise on this side.Difference maps were performed at each subsequent visit. No evolution was observed between the first and last visits. The keratoconus is stable for over 15 months .
This patient has stopped rubbing his eyes .
ORBSCAN RIGHT EYE (2nd VISIT)
DIFFERENTIAL PENTCAM MAPS : RIGHT EYE. This subtraction map (last column) shows the absence of keratoconus evolution. This stabilization has been achieved by simply a strict cessation of eye rubbing.
ORBSCAN RIGHT EYE (3rd VISIT)
PENTACAM DIFFERENTIAL MAPS : RIGHT EYE (between 1st and 3rd VISITS). This subtraction map (last column) shows the absence of keratoconus evolution, achieved by a strict cessation of eye rubbing. 
ORBSCAN RIGHT EYE (4th VISIT)ORBSCAN RIGHT EYE (4th VISIT)
DIFFERENTIAL PENTCAM MAPS : RIGHT EYE. This subtraction map (last column) shows the absence of keratoconus evolution. This stabilization has been achieved by simply a strict cessation of eye rubbing.
ORBSCAN LEFT EYE (2nd VISIT)
DIFFERENTIAL PENTCAM MAPS : LEFT EYE. This subtraction map (last column) shows the absence of keratoconus evolution. This stabilization has been achieved simply by a strict cessation of eye rubbing.
ORBSCAN LEFT EYE (3rd VISIT)
PENTACAM DIFFERENTIAL MAPS : LEFT EYE (between 1st and 3rd VISITS). This subtraction map (last column) shows the absence of keratoconus evolution, achieved by a strict cessation of eye rubbing. 
ORBSCAN LEFT EYE (4th VISIT)ORBSCAN LEFT EYE (4th VISIT)
DIFFERENTIAL PENTCAM MAPS : LEFT EYE. This subtraction map (last column) shows the absence of keratoconus evolution. This stabilization has been achieved by simply a strict cessation of eye rubbing.This case reveals that eye rubbing can often be associated with long hours of overnight shifts and/or time spent in front of the screen, which causes visual fatigue associated with dry eye (reduced blinking). These sensations are often relieved (transiently) by eye rubbing, which as described by patients, can be pleasurable and relaxing in such circumstances. These repeated and sustained frictions are over the long-term are responsible for a pathological permanent warpage of the cornea, culminating in the condition called « keratoconus ». Rubbing with the fists and knuckles is particularly detrimental to the corneas, because the knuckles are the hardest part of the hands.
Cessation of eye rubbing and treatment of the underlying dry eye are sufficient in such cases.
